Gestational diabetes Q & A

2 Mar 2012

GESTATIONAL DIABETES
MANAGEMENT
Iris Thiele Isip Tan MD, MSc, FPCP, FPSEM
Clinical Associate Professor, UP College of Medicine

Wednesday, November 21, 12

Q1

Which of the following
women will you screen for
gestational diabetes?

a) 25 y.o. G1P0 whose mother has
diabetes

b) 38 y.o. G3P0 with recurrent ﬁrst-
trimester abortions

c) 27 y.o. G2P1

d) All of the above


Unite for Diabetes CPG 2010

All pregnant women
should be screened for GDM.


Risky

Filipino women are at increased
risk for diabetes in pregnancy.

ASGODIP Data n/N
Low risk 35/853
High risk 136/350
171/1203
Overall
14.2%
Litonjua AD et al. AFES Study Group on Diabetes in Pregnancy:
Preliminary Data on Prevalence. PJIM 1996:34:67-68.


Risky
Macrosomia Shoulder Dystocia

Increased
risk of
perinatal
morbidity

Birth injuries Hypoglycemia
http://www.flickr.com/photos/mikewade/3267336862/ http://www.flickr.com/photos/jessicafm/280232106/
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Risky
Cesearean Section Preeclampsia

Increased
risk of
maternal
morbidity

Pregnancy-induced hypertension Type 2 diabetes mellitus
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http://www.flickr.com/photos/j2dread/4501366303/
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International Diabetes
Federation (2009)
Global Guideline on
Pregnancy and Diabetes

“... women with GDM without risk
factors appear to be no different from
women with GDM and risk factors.”


Q2

Which of the following factors
best predict risk of GDM?

a) prior history of GDM

b) glucosuria

c) family history of diabetes

d) prior macrosomic baby


Prior history of GDM (OR 23.6 [95%CI 11.6, 48.0])3
Glucosuria (OR 9.04 [95%CI 2.6, 63.7]2; PPV 50% 4)
Family history of diabetes (OR 7.1 [95%CI 5.6, 8.9]1;
OR 2.74 [95%CI 1.47, 5.11]3)
Prior macrosomic baby (OR 5.59 [95%CI 2.68, 11.7])3
Age >25 years old (OR 1.9 [95%CI 1.3, 2.7]1; OR 3.37
[95%CI 1.45, 7.85]3)

Risk Factors for GDM
UNITE
CPG


Diagnosis of polycystic ovary syndrome (OR 2.89
[95%CI 1.68, 4.98])5

Overweight or obese before pregnancy
(BMI >27 kg/m2 OR 2.3 [95%CI 1.6, 3.3]1; BMI>30 kg/
m2 OR 2.65 [95%CI 1.36, 5.14]3
Macrosomia in current pregnancy (PPV 40% 4)
Polyhydramnios in current pregancy (PPV 40% 4)
Intake of drugs affecting carbohydrate metabolism

Risk Factors for GDM
UNITE
CPG


Q3

For pregnant women, when
should testing be done?

a) Test high-risk women at the soonest
possible time
b) Women without risk factors should be
tested between 24-28 wks AOG
c) Testing for gestational diabetes should still
be carried out in women at risk even beyond
24-28 wks AOG
d) All of the above


ASGODIP (Veterans Memorial Medical Center)
AOG tested
% 21-30 31-40
<20 weeks
weeks weeks
n=19
n = 74 n = 60
Negative
95 92 85
for GDM
Positive
5 8 15
for GDM
Bihasa MTG et al. Screening for gestational diabetes: Report from ASGODIP
participating hospital: Veterans Memorial Medical Center. PJIM 1996:34:57-61.

Testing


Q3

For pregnant women, when
should testing be done?

a) Test high-risk women at the soonest
possible time
b) Women without risk factors should be
tested between 24-28 wks AOG
c) Testing for gestational diabetes should still
be carried out in women at risk even beyond
24-28 wks AOG

d) All of the above


Q4

Which test should be used to
screen for GDM?

a) 75-g OGTT

b) 100-g OGTT

c) 50-g GCT

d) FBS


★ Capillary blood glucose
★ RBS
★ Fructosamine
★ FBS
★ Hba1c
★ Urine glucose

NOT to be used
for diagnosis of GDM
Use
OGTT


One-
step

50-g glucose Oral glucose
challenge tolerance test (OGTT)
test (GCT) 75-g or 100 g

“A one-stage deﬁnitive
procedure is preferred.”
International Diabetes Federation (2009)
Global Guideline on Pregnancy & Diabetes


OGTT

100-g OGTT
high glucose
load often
unpalatable
100-g OGTT
duration
75-g OGTT
100-g more 3 hours
international
cumbersome;
standard in
4 blood
non-pregnant
samples


CPG

Philippine Diabetes CPG has
endorsed the use of the 75-g OGTT.


Q5

Which of the following is true
of the OGTT procedure?

a) Low CHO intake for past 3 days

b) Fast for 10 to 16 h

c) Slow walking is not permitted

d) Supine position during test


CHO intake of at least 150 g/day 3 days prior
Fast for 10 to 16 hours
75 grams of anhydrous dextrose powder as
chilled 25% solution (400 cc) ﬂavored with
calamansi
Drink within 5 minutes (ﬁrst swallow is time zero)
Terminate test should nausea and vomiting occur

Collect samples at 0, 1 and 2 hours

OGTT


Abstain from tobacco, coﬀee, tea,
food and alcohol during test

Sit upright and quietly during the test

Slow walking is permitted but avoid
vigorous exercise

OGTT


Q6

Which of the following results
is/are consistent with GDM?

a) 75-g OGTT: FBS 90 1h 190 2h 150

b) 75-g OGTT: FBS 98 1h 190 2h 150

c) 100-g OGTT: FBS 98 1h 190 2h 150
3h 140

d) All of the above


CPG

Thresholds ADA IADPSG
for
diagnosis 100-g 75-g 75-g*

FBS 95 95 92
1h 180 180 180
2h 155 155 153
3h 140 - -

* Requires only 1 threshold value exceeded


Q6

Which of the following results
is/are consistent with GDM?

IADPSG
a) 75-g OGTT: FBS 90 1h 190 2h 150
ADA
b) 75-g OGTT: FBS 98 1h 190 2h 150

c) 100-g OGTT: FBS 98 1h 190 2h 150
3h 140 ADA
d) All of the above


OGTT

ACOG recommends against
IADPSG consensus
Diagnosis of GDM based on the 1-step
screening and diagnosis test outlined in the
IADPSG guidelines is not recommended at
this time because there is no evidence that diagnosis
using these criteria leads to clinically signiﬁcant
improvement in maternal or newborn outcomes, and it
would lead to a signiﬁcant increase in healthcare costs.

ACOG Committee on Obstetric Practice. Screening & Diagnosis of
Gestational Diabetes Mellitus. Obstetrics & Gynecology 2011; 118(3):751-3


Q7

Which of the following is TRUE of
dietary management for GDM?

a) Do NOT prescribe less than 1500 cal/day for
multiple pregnancy
b) For overweight women, reduce energy
intake by no more than 30% of habitual intake
c) Monitor urine ketones at bedtime to detect
starvation ketonuria
d) Non-caloric sweeteners are NOT allowed.


Diet

Recommended Daily
Caloric Intake

Pregravid BMI Category kcal/kg/day
Low (BMI <18.5 kg/m2) 36-40
Normal (BMI 18.5-24.9 kg/m2) 30
High (BMI 25-29.9 kg/m2) 24
Obese (BMI >29.9 kg/m2) 12

Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)


Diet

For considerably overweight women
with GDM, reduce energy intake by no
more than 30% of habitual intake

Total cal/day = 1,800-2,000
Not less than 2,000 cal/day if multiple
pregnancy

International Diabetes Federation (2009)
Global Guideline on Pregnancy and Diabetes


“Non-c aloric sweeteners may
be used in moderation.”
ADA GDM Position Statement 2004


Q8

For a woman with normal BMI,
what is the allowed weight gain
in pregnancy?

a) <28-40 lbs
b) 25-35 lbs
c) 15-25 lbs
d) 11-20 lbs


Weight gain during pregnancy
12.5 kg British cohort of >3800 primigravidae
eating without restriction

Product of conception
Fetus, placenta, amniotic ﬂuid

Maternal tissue expansion
Uterus, breasts, blood volume

Maternal fat reserve
Text


Rates of weight gain*
Prepregnancy Total weight
2nd and 3rd
BMI gain (lbs)
trimester (lbs/week)
Underweight 1
<28-40
BMI <18.5 (1-1.3)
Normal weight 1
25-35
BMI 18.5-24.9 (0.8-1)
Overweight 0.6
15-25
BMI 25.0-29.9 (0.5-0.7)
Obese 0.5
11-20
BMI >30.0 (0.4-0.6)
* Assume a 0.5-2.0 kg (1.1-4.4 lbs)
weight gain in the ﬁrst trimester

IOM


Q9

self-monitoring of blood glucose?

a) For women on dietary intervention alone,
monitor BG 6x a day.
b) For women treated with insulin, postprandial
monitoring is superior to pre-prandial.
c) If on insulin, test BG before breakfast to detect
hypoglycemia.
d) Daily SMBG does not appear to be superior to
intermittent ofﬁce monitoring.


“For women treated with insulin, limited
evidence indicates that postprandial
monitoring is superior to preprandial
monitoring.” ADA GDM Position Statement 2004


Diet only
Monitor BG 4x a day (prebreakfast and 1 h
after the ﬁrst bite of food at each meal)
AACE 2007


Q9

self-monitoring of blood glucose?

a) For women on dietary intervention alone,
monitor BG 6x a day. 3x a day
b) For women treated with insulin, postprandial
monitoring is superior to pre-prandial.
c) If on insulin, test BG before breakfast to detect
hypoglycemia. Test at night
d) Daily SMBG does not appear to be superior to
intermittent ofﬁce monitoring.


Q10

What are the targets for
SMBG?

a) Between 60 to 90 mg/dL for fasting and less
than 120 mg/dL 1 hour after the ﬁrst bite of food
at each meal (postprandial)
b) Not more than 95 mg/dL for fasting and less
than 120 mg/dL 2 hours postprandial
c) 90 mg/dL for fasting and less than 140 mg/dL
2 hours postprandial
d) None of the above


Between 60 to 90 mg/dL (fasting) and
less than 120 mg/dL (1 hour after the
ﬁrst bite of food at each meal)
AACE 2007


Q11

Can we give Metformin
for GDM?

a) Yes
b) No


★ Use of Metformin or glibenclamide
during pregnancy NOT an approved
indication

★ Discuss with patients

★ Obtain and document informed consent.

Canadian Diabetes Association 2008

METFORMIN: Off-label use

OHA


Insulin remains the
agent of choice
“In poorly resourced areas
of the world, the
theoretical disadvantages
of using oral glucose-
lowering agents ... far less
than the risks of non-
treatment.” IDF 2009

Insulin


Q12

When and how should insulin
be started in GDM?

a) Consider insulin when diet and exercise fail to
maintain glucose targets in 1-2 weeks
b) Ultrasound shows incipient fetal macrosomia
(AC >70th percentile)
c) Start daily insulin at 0.1-0.3 u/kg BW
d) All of the above


Insulin Initiation
ADA Protocol
Fasting whole BG >95 mg/dL
1-h postprandial whole BG >140 mg/dL
2-h postprandial whole BG >120 mg/dL

Dr. Jovanovic
Fasting plasma glucose >90 mg/dL (5 mmol/L)
1-h PP whole BG >120 mg/dL (6.7 mmol/L)
Insulin

Jovanovic L (Ed). Medical Management of Pregnancy Complicated by Diabetes (2009)


Q13

Which of the following is true of
management during labor?

a) Give dextrose-containing IV ﬂuids
b) Give short-acting insulin for CBG>140 mg/dL
c) Check CBG q hourly.
d) All of the above


Protocol for Spontaneous Delivery

Infusion of 500 ml 5% dextrose/saline
x4h
CBG q 4h
Give short-acting insulin for CBG >140
mg/dL
L
- Do se equal to mmol of CBG i.e. 12 u for 12 mmol/
u for
- Dose equal to 1/20th of mg/dL of CBG i.e. 12
240 mg/dL
Omit insulin for CBG <140 mg/dL

ASGODIP


After delivery

Resume diet
GDMs with high insulin requirements
during pregnancy should have
glucose proﬁles
Give insulin if BG persistently high
(>200 mg/dL)

ASGODIP


Q14

Which of the following is true of
postpartum follow-up?

a) Schedule 75-g OGTT 6 weeks after follow-up
b) Measure FBS every 3 years
c) Advise patient not to get pregnant again
d) Breastfeeding should be limited


Jovanovic L (Ed). Medical Management of
Pregnancy Complicated by Diabetes (2009)

Annual follow-up
Measure FBS
Assess weight reduction
Review pregnancy plans


Ff-up

All patients with prior GDM
should be educated re:
lifestyle modiﬁcations

Maintain normal body weight:
MNT and physical activity

Women with IFG or IGT
postpartum: intensive MNT and
individualized exercise program
ADA GDM Position Statement 2004


Ff-up

Planning subsequent
pregnancies

Plan future pregnancies in
consultation with health
care provider

Assess glucose tolerance
prior to conception to
assure normoglycemia at
time of conception
Canadian Diabetes Association 2008


Thank You
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@endocrine_witch

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